Analysis of acute presentations for child protection medical assessments in a large, culturally diverse metropolitan setting.

OBJECTIVE: South Western Sydney has a large culturally diverse population with many vulnerable subgroups; little is known about the health and social outcomes following acute child maltreatment assessments. We aimed to describe acute presentations of maltreatment in South Western Sydney-including examination findings of the assessment, determine health and social outcomes for children following medical assessment, to inform service development.
DESIGN: We gathered data from the acute child protection database on all children <16 years referred for physical abuse and neglect and/or sexual abuse assessment between 2013 and 2015 to one hospital service. We reviewed clinical records of the children assessed, using the reports to classify findings of the examination. We performed simple descriptive analysis on the data.
RESULTS: There were 304 children referred, 279 seen for acute assessment. Most (72%) were female, 204 (73%) referrals were for sexual abuse, 75 (27%) were for physical abuse and neglect. There were age, gender and ethnicity differentials depending on type of maltreatment presentation. Twelve per cent of sexual and 19% of physical abuse cases were found not to be abuse related. Unmet medical, developmental and behavioural concerns were identified in the majority (54%) assessed. Just under half (48%) of all children went home with families with no statutory agency support; those seen for physical abuse were more likely to be placed in care (p<0.001).
CONCLUSIONS: Children assessed for child maltreatment had a range of health and social concerns identified, needing further intervention. Comprehensive medical assessments have a critical role to play in child protection assessments.

A comprehensive medical assessment is an essential component of child maltreatment assessments.

Maltreated children are more likely to be hospitalised and use frontline services.

Child maltreatment assessments are important for forensic purposes but may identify other health concerns.

Child maltreatment medical examinations can be used to help identify unmet health and welfare needs of the child.

There are differences in the health, social and welfare outcomes when comparing sexual abuse and physical abuse assessments within a metropolitan region.

There is significant variation in age, gender and ethnicity in children presenting for child maltreatment assessments.

Introduction

Child maltreatment (CM) is now acknowledged as a global public health and social welfare problem, with known significant short-term, medium-term and long-term health consequences.1–6Over recent decades, there has been an increased focus on the health needs of maltreated children,6–8 along with targeted health services and clinical assessments guidelines.9–11 A comprehensive medical assessment is an acknowledged essential component of a multiagency investigation of CM.10

Maltreated children are more likely to be hospitalised and use frontline services such as emergency departments and paediatric departments.12–14 There is now good evidence for performing comprehensive medical assessments for acute presentations of CM,2 not just for forensic purposes but because of the high yield of health concerns identified.15 What is not known is the health, social and welfare outcomes following acute assessments for CM or the quality dimensions of these assessments. South Western Sydney (SWS) Local Health District is the largest, most populous region in Australia, with a substantial child and youth population.16 It is a rapidly growing metropolitan population in the state of New South Wales (NSW), Australia, with a culturally and linguistically diverse population and many subgroups who are socially and economically at risk within its boundaries.17 Raman et al18 previously identified a wide variation in clinical practice in acute assessment for child physical abuse and neglect (PAN) from a quality audit conducted in SWS. Following that audit, the Community Paediatrics team in SWS made improvements to clinical assessment processes, which included the establishment of a joint clinic made up of community paediatricians (CP), social workers and sexual assault physicians. A model of collaborative multidisciplinary clinical assessments for acute CM in one hospital (a non-tertiary paediatric hospital) setting was established.

Our aims were to describe the acute presentations of CM to this collaborative clinical service, including the examination findings, health concerns and social outcomes for children following the clinical and/or forensic medical assessment. The results of this service evaluation would further feed back into clinical service improvements in SWS, thereby contributing to and sustaining the quality improvement process.19

Methods

We collated data gathered from the acute child protection databases for all referrals for acute assessments to one hospital service in SWS of children and youth (<16 years old) between 1 January 2013 and 31 December 2015, including PAN and sexual assault (SA). These data were derived from two databases, one established by CP and the other from SA services. Those children that appeared in both databases for the same assessment were categorised as a joint assessment conducted collaboratively by CP and SA physicians. Only children referred to this hospital service were analysed. Other children within SWS that may have presented to other services within the area were not included in this study.

We reviewed all the clinical reports, clinical notes and follow-up plans of children seen for CM assessments. Demographics, referral details, forensic, clinical and social outcomes were recorded from the available data. The term forensic assessment is used for CM assessments that were conducted specifically for criminal proceedings, done at the request of the Joint Investigative Response Team (interagency team including Community Services, police and health) or the police to aid legal matters.

We used the conclusion of the medical or forensic notes and reports to classify the findings of the medical examination (table 1). The health needs identified in the reports were classified as medical, developmental/learning and behavioural/mental health or a combination of two or all areas. The referring services were contacted to find out what happened to the children following their acute assessments and whether any criminal proceedings had occurred. Social outcomes were divided into whether the child went home with their family with or without community services involvement or whether they were placed in out-of-home care.

Table 1

Categories of findings from medical assessment

SA	Description
Definite evidence of abuse	Includes witnessed sexual molestation, gonorrhoea infection
Anogenital injury	Injury consistent with suggestion of penetration, not including straddle injury
No anogenital findings	Examination was normal, cannot confirm penetration or deny
No injury, other CM concerns	Examination was normal; however, other CM concerns were identified during the assessment
Not consistent with abuse concerns	Includes findings of normal/variant vaginal examination with no disclosure/behavioural change, finding other conditions that mimic, that is, lichen sclerosis, or accidental injury such as a straddle injury.
Refused examination	Child declined consent for the examinations and therefore unable to assess the genitals.

CM, childmaltreatment; SA, sexual assault.

Analysis

Relevant data extracted from the databases were entered into an Excel spreadsheet and simple descriptive analysis of the data was carried out using IBM SPSS Statistics for Windows, V.23. Mann-Whitney U test and χ2 tests were used to determine difference in proportions.

Ethics approval was obtained via the lead Human Research Ethics Committee at Liverpool Hospital.

Results

Over the 3-year period (2013–2015), 304 cases were referred for an acute CM assessment, of which 25 (8%) were phone consultations. There were 279 cases seen for an acute assessment, 204 cases (73%) were seen for SA and 75 cases (27%) were for PAN assessments. Of the 279 cases, 15 cases (5%) seen were siblings of an index child and one child was seen for neglect.

Table 2 lists the demographics, referral and assessment details of children seen. Median age of all types of assessments was 7 years (IQR 3–13 years); there were differences in age, gender and ethnicity depending on type of presentation. Median age of children presenting for all SA assessments was 10 years (IQR 4–14 years), for PAN was 3.5 years (highly significant, Mann-Whitney U test Z score=6.84, p<0.0001). Girls were three times more likely to be seen for an acute CM assessment than boys, and females were more likely to present for acute SA assessments (χ2 53.89, p<0.001). The majority of the children seen for CM assessment were identified as Anglo–Australian (27%) with high numbers of Aboriginal and Pacific Islander children. Ethnicity was not documented in 37% per cent of SA assessments carried out by the SA doctors. Police and/or child protection agencies made 82% of the referrals for acute assessments. A third of the SA assessments were joint (CP/SA) assessments. A third of all assessments were for forensic purposes.

Table 2

Demographic description, referral and assessment details of acute child maltreatment assessments, South Western Sydney 2013–2015

	Sexual abuse SA Dr only	Sexual abuse joint	Physical abuse and neglect	Total
	n=134 (48%)	n=70 (25%)	n=75 (27%)	n=279
Age (median)	13 years*	5.5 years	3.5 years	7 years
IQR	6.3–14 years	3.2–9 years	1.5–8 years	3–13 years
Gender
Male  Female	12 (9%) 122 (91%)*	20 (29%) 50 (71%)	45 (60%) 30 (40%)	77 (28%) 202 (72%)
Ethnicity
Anglo–Australian  Aboriginal  Pacific Islander  Middle Eastern  Asian  European  African  Other  Not documented	28 (21%) 17 (13%) 8 (6%) 13 (10%) 8 (6%) 3 (2%) 5 (4%) 2 (1%) 50 (37%)	29 (41%) 13 (19%) 7 (10%) 9 (12%) 5 (7%) 4 (6%) 2 (3%) 1 (2%) 0 (0%)	20 (27%) 9 (12%) 20 (27%) 12 (16%) 8 (10%) 3 (4%) 2 (3%) 1 (1%) 0 (0%)	77 (27%) 39 (14%) 35 (13%) 34 (12%) 21 (8%) 10 (4%) 9 (3%) 4 (1%) 50 (18%)
Referring agency
JIRT  Police  CS  Emergency doctor  Paediatrician  Other	77 (56%) 33 (25%) 3 (2%) 19 (14%) 0 (0%) 2 (1%)	59 (85%) 1 (1%) 4 (6%) 1 (1%) 4 (6%) 1 (1%)	29 (39%) 1 (1%) 21 (28%) 6 (8%) 17 (23%) 1 (1%)	165 (59%) 35 (13%) 28 (10%) 26 (9%) 21 (8%) 4 (1%)
Who assessed
SA Doctor  Joint (SA and CP)  Community paediatrician  Paediatricians	134 (100%) 0 (0%) 0 (0%) 0 (0%)	0 (0%) 70 (100%) 0 (0%) 0 (0%)	0 (0%) 0 (0%) 59 (79%) 16 (21%)	134 (48%) 70 (25%) 59 (21%) 16 (6%)
Type of assessment
Medical  Forensic  Refused examination	55 (41%) 65 (49%) 14 (10%)	63 (90%) 5 (7%) 2 (3%)	48 (64%) 27 (36%) 0 (0%)	166 (59%) 97 (35%) 16 (6%)

*p value <0.001.

CP, community paediatricians; CS, Community Services, statutory child protection agency; JIRT, Joint Investigation Response Team, comprising health, welfare and police; SA, sexual assault.

Table 3 lists the clinical findings from SA assessments, 12% seen for an acute SA assessment had findings not consistent with abuse concerns while 9% of SA assessments had definite evidence of abuse or anogenital injury. The majority of SA assessments (71%) had normal genital findings, 26% of all SA assessments (62% of the joint SA assessments) identified other CM concerns. Table 4 lists the clinical findings from PAN assessments, 14% were not concerning for abuse, 39% were definitive or suspicious for inflicted injury, 28% of assessments identified other CM concerns. Overall, 30 (11%) of all CM assessments found no concerns for abuse.

Table 3

Clinical examination findings: sexual assault (SA) assessments

Findings	Total	SA medical only	Joint assessments
	n=204	n=134	n=70
Definite evidence of abuse	3 (1%)	3 (2%)	0 (0%)
Anogenital injury	17 (8%)	14 (10%)	3 (4%)
No anogenital findings	91 (45%)	78 (59%)	13 (18%)
No injury, other child maltreatment concerns	53 (26%)	10 (8%)	43 (62%)
Not consistent with abuse concerns	24 (12%)	15 (11%)	9 (13%)
Refused examination	16 (8%)	14 (10%)	2 (3%)

Table 4

Clinical examination findings: physical abuse and neglect (PAN) assessments

Findings	n=75
Definite inflicted injury/abuse	6 (8%)
Suspicious for inflicted injury	23 (31%)
Unclear for abuse	11 (14%)
Unclear, other CM concerns	21 (28%)
Not concerning for abuse, accidental injury	14 (19%)

Table 5 lists health and social outcomes following CM assessments; 151 (54%) of the 279 children examined had other health concerns identified during their acute assessment. A quarter of the unmet needs were medical which included dental caries, incomplete immunisation, growth and nutrition, pneumonia, hearing issues, missed vision screening, skin infections and current gastroenteritis. Learning concerns included developmental delays or issues with cognition and learning at school and this was an issue for 28 children (19%). Twenty-one children (14%) had unmet mental health or behavioural issues which included depression, suicidal ideation, emotional dysregulation, attention deficit hyperactivity disorder, obsessive compulsive disorder and eating disorders. All three health concerns were seen in 25 children (17%). For SA assessments, joint assessments were better at identifying health concerns for children than those assessments carried out by SA physicians solely (χ2 = 72.33, p<0.001). Just under half of the children seen for all CM assessments went home with their families with no child protection statutory agency support; those seen for SA assessments were more likely to go home with their parents (χ2 = 75.74, p<0.001). Just under half of PAN assessments resulted in children being placed in care (χ2 = 24.32, p<0.001). Fifteen per cent of the cases seen for a CM assessment resulted in the person of interest charged.

Table 5

Health concerns identified and social outcomes following child maltreatment assessment

Outcomes	SA n=134	Joint n=70	PAN n=75	Total CM n=279
No health concerns identified Medical concerns Learning concerns Behavioural concerns Two health concerns 3+ health concerns Total health concerns identified	99 (74%) 5 (4%) 4 (3%) 12 (9%) 10 (7%) 4 (3%) 35 (26%)	10 (14%) 16 (23%) 13 (19%) 4 (6%) 13 (18%) 14 (20%) 60 (86%)*	19 (25%) 19 (25%) 11 (15%) 5 (7%) 14 (19%) 7 (9%) 56 (75%)	128 (46%) 40 (14%) 28 (10%) 21 (8%) 37 (13%) 25 (9%) 151 (54%)
Safety
Home with family  Home with family with CS support  Placed in out-of-home care	104 (78%)* 19 (14%) 11 (8%)	19 (27%) 26 (37%) 25 (36%)	11 (14%) 29 (39%) 35 (47%)*	134 (48%) 74 (27%) 71 (25%)
Legal
Proceeded to criminal court  Person of Interest found guilt	26 (19%) 15 (12%)	6 (9%) 3 (4%)	9 (12%) 5 (7%)	41 (15%) 23 (8%)

*p value < 0.001.

CM, child maltreatment; CS, Community Services, statutory agency; PAN, physical abuse and neglect; SA, sexual assault.

Discussion

In this study of CM medical assessments in metropolitan Sydney, more than half of the assessments identified other health concerns, in keeping with other international research.15 20 In a quarter of assessments, multiple types of CM were identified in children who presented with one type. We identified age, gender and ethnicity differentials in the CM assessments, and health and social outcomes following assessments; all critically important information for planning and responding to CM in this region.

In our study, we found males were more likely to present for PAN assessments, while more females presented for SA assessments, in keeping with much of the international published data.21 22 We found that three-quarters of the acute CM assessments were for concerns about SA, less than a third were for physical abuse/neglect; these findings differ from the study from the UK, which showed 52% of assessments were for alleged physical abuse, 36% for sexual abuse and 3% for neglect.15 This is despite SA being the least likely reason to be referred to child protection statutory agencies both in Australia23 and globally.24–26 This over-representation of SA for clinical assessments in our sample may be due to the need for forensic examination for the purpose of collecting evidence following an alleged assault and the fact that we had access to a specialist SA team to do this.

There was significant variation in ethnicity in children presenting for CM assessments, with over-representation of Aboriginal and Pacific Islander children, compared with around 2% of SWS and around 3% of NSW populations.16 27 The over-representation of black and ethnic minority populations has been well documented in international studies.28–30 There is clearly more work to be done to unpack the role and influence of culture, both in heightening and ameliorating risks; there is a complex interplay of sociocultural factors in this arena.31 Our data is the basis of another service improvement project that we have carried out in SWS,32 to help understand that gap.

In our study, about 40% of the PAN assessments had findings that were suspicious or definitive for inflicted injury, compared with 9% of SA assessments that confirmed abuse and/or anogenital injury. Of all our CM assessments, 14% were found to have examinations that were not consistent or concerning for abuse. These results are similar to Kirk et al’s findings from the UK15; they found that two-thirds of PAN, one-fifth of SA assessments strengthened abuse allegations and 15% of all assessments repudiated allegations. However, the thresholds for referral for SA and PAN assessments are different and may reflect the difference between SA and PAN concerns for suspicious/definitive injury. SA may present via the child’s disclosure, whereas physical abuse may present with concerns around physical signs and suspicious injuries that need investigation.

In keeping with the other studies,33–36 our findings showed that the majority (71%) of SA assessments had a normal genital examination following allegations or concerns for abuse. This highlights the growing importance of the child’s disclosure as well as the importance of doing an assessment soon after the alleged SA.35 37 Our study picked up other CM concerns in 26% of SA assessments and 28% of PAN assessments, similar to Kirk’s study.15 This finding supports the understanding that children exposed to one type of CM are often exposed to other types especially neglect, psychological abuse and intimate partner violence.1

Over half of the CM assessments identified other health concerns and 41% of those children had two or more unmet health concerns in our setting. Our study reflected findings from other international studies,15 20 38 39 which shows that CM medical examinations can be used to help identify unmet health and welfare needs of the child. We would argue that an acute assessment for CM goes past the forensic requirement, is comprehensive in nature and provides holistic care and support to the child and family.

Eighty per cent of CM is perpetrated by parents or parental guardians, apart from SA, which is most perpetrated by other relatives or acquaintances,1 which explains why nearly half of the PAN assessments resulted in the children being placed in foster care. The overall management of CM cases needs complex decisions based on medical, social, ethical and legal issues, which is beyond the expertise of a single individual or service. Many children will have police involvement; however, as our study showed, only a few lead to criminal proceedings and an even smaller number will the perpetrator of abuse be found guilty. It is hard to know, if at all, whether the medical assessments contribute to that solely; from Hansen et al’s Danish study,40 the child’s statement and not the physical findings were important for legal outcome in SA forensic assessments.

Limitations

This collaborative child protection clinical service in SWS is a unique service for CM assessments and, therefore, it may not reflect practice elsewhere. This service certainly does not assess all children with maltreatment needing clinical assessment in the region. There would be a proportion of children, especially those with PAN, who may have been referred directly to other district or tertiary hospitals. Our results show an under-representation of neglect with only one child referred for an acute assessment. We had to rely on what was documented in the clinical records and documentation can be notoriously variable.41 42 The conclusion of the report was used to categorise findings and we did not reinterpret the findings. Although there is an extensive proposed classification system for examination findings in SA,9 there is no equivalent system for PAN and there is wide variability in the interpretation of physical abuse even among experienced clinicians.41

Conclusions

This study describes comprehensively the health needs and social outcomes following acute CM presentations within a defined geographical region in Australia. The findings from this clinical service evaluation can be used to shape better and more targeted clinical services for CM assessments. The medical assessment for CM is not only useful for forensic collection, documenting clinical examination findings and identification of other CM concerns; crucially, it helps to identify health and welfare needs of the child and therefore pathways to intervention.